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oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Women have a lifetime risk of depression of about 1 in 4 and it is most prevalent during their reproductive years. Much emphasis has been placed on the detection and treatment of postnatal depression because of the morbidity in mother and child. However antenatal depression is actually more frequent and about half of postnatal depression appears to start antenatally.

Relationships are often under pressure - domestic violence increases during pregnancy.

Pregnancy-related sex steroids increase activation of the hypothalamic-pituitary-adrenal axis (the cortisol stress system) which is associated with depression. Some investigators have suggested that high levels of cortisol may effect fetal growth and development and be associated with altered temperament and behaviour.[2]

Many women stop antidepressant medication due to concerns about potential harm to their developing fetus - this underlies high rates of relapse in pregnancy.[3]

Depressed women are more likely to smoke and drink alcohol and less likely to attend for antenatal care - one behavioural pathway mediating poorer obstetric and neonatal outcomes.

The National Institute for Health and Clinical Excellence (NICE) advises against using single risk factors to predict individuals at risk of antenatal mental illness.[6] A Cochrane review concluded that there was insufficient evidence to suggest that the use of psychosocial risk assessments improves perinatal mental health outcomes.[7]

Vigorous exercise (3-5 times a week, raising the heart rate to 70-80% of maximum) may have a protective effect.[8]

Presentation

The signs and symptoms of antenatal depression are as for depression in general. See separate article on Depression. However, if one focuses on somatic symptoms (eg fatigue, insomnia, appetite changes), pregnancy symptoms may mask those of depression, particularly in the first trimester. Thus, the psychological symptoms (eg anhedonia, hopelessness, guilt) may be more reliable during pregnancy.

The Diagnostic and Statistical Manual of Mental Disorders - fourth edition (DSM-IV) recognises postpartum-onset mood disorders but does not refer specifically to depression during pregnancy.

Screening

Identifying antenatal depression is potentially difficult - women are reluctant to acknowledge 'difficult' emotions rather than the 'bloom' expected in pregnancy and many of the biological symptoms of depression can also be attributed to the pregnancy itself. NICE guidelines[6] suggest that health professionals (whether midwives, GPs, health visitors or obstetricians) should screen pregnant women at first contact and at booking with 2 questions:

During the past month, have you often felt bothered by feeling low, depressed or hopeless?

During the past month, have you often been bothered by having little interest or pleasure in doing things?

If the woman answers 'yes' to either of the above, then a third question should be asked:

Is this something you need or want help with?

Use of self-report measurement tools may be helpful in further assessment or for monitoring of response to treatment, but should not be used for diagnosis.

Women with depression and those caring for them need to balance risks to the woman's health and the potential fetus' development:

The risk to fetus and neonate posed by medication. There is conflicting evidence regarding the risk of congenital malformations associated with some psychotropic medications. Since these are such rare events, it is often difficult confidently to quantify the risk or establish causation.

The risk of untreated mental illness.

The risk of abrupt cessation of current medication.

Guidelines recommend treatment options dependent on severity of depression, past history of affective disorder and maternal preference.[6] As there has been concern about the risk associated with antidepressant use during pregnancy, the threshold for use of psychological treatments is much lower at this time but the availability of psychological treatments has obvious implications.

Watchful waiting

Where an individual has had mild depression treated with antidepressants and is pregnant/intends to become pregnant, withdraw the drugs gradually and monitor regularly.

Self-help

This is suggested where intervention is required for mild-to-moderate depression without a previous history of depression. Possibilities include:

Guided self-help.

Computerised cognitive behavioural therapy (C-CBT).

Alternatives, where available, would be nondirective counselling ('listening visits') or brief psychological treatment (usually 4-6 sessions of CBT or interpersonal psychotherapy).[4] Other approaches such as massage and acupuncture have not been shown to be beneficial.[10]

IPT and CBT

These therapies have been shown to be effective for milder cases in one small trial, but evidence is extremely limited.[11] Also, the time to response is longer than with medication. Psychological treatments may be considered for moderate or severe depression where a woman opts for this in preference to drug treatment or in combination with antidepressant medication. They should also be considered with mild depression with episodes of more severe depression in the past.

Antidepressants

Discussion of the potential risks of antidepressants in pregnancy should occur prior to prescribing them to women of child-bearing age. Two thirds of women with a history of recurrent depression will relapse during pregnancy if they discontinue their medications after conception.[1]

When prescribing antidepressants to pregnant women or women who intend or may become pregnant, consider:

Tricyclics are considered lower risk than newer antidepressants during pregnancy but have a higher fatal toxicity index than selective serotonin reuptake inhibitors (SSRIs).

SSRIs:

It is estimated that about 2-3% of current pregnancies are exposed to SSRIs.[12]

The UK Teratology Information Service notes that the available data on first trimester paroxetine exposure and SSRIs as a class are conflicting and that if there is an association between paroxetine exposure and cardiovascular malformations, the absolute increase in risk appears to be small.[13] However SIGN advises against initiating paroxetine as first line treatment in pregnancy.

An increased risk of omphalocele with the use of sertraline has been suggested.[14]

Exposure to SSRIs during the third trimester may be associated with persistent pulmonary hypertension of the newborn.

MHRA advice is to consider potential risks in the context of the benefits of treatment when making prescribing decisions concerning SSRIs in pregnant women or women who may become pregnant.

Imipramine, nortriptyline and sertraline are present in breast milk at relatively low levels whilst citalopram and fluoxetine are present at much higher levels.

Venlafaxine increases blood pressure during pregnancy and has a higher toxicity in overdose compared with SSRIs and some tricyclics. In general, the advice is to avoid mirtazapine, reboxetine, moclobemide or venlafaxine.

Avoid St John's wort in pregnancy.

All antidepressants carry the risk of withdrawal or toxicity in the neonate. Normally this is mild and self-limiting. Serotonin withdrawal syndrome is a self-limiting condition with usual neonatal symptoms including hypotonia, irritability, excessive crying, sleeping difficulties and mild respiratory distress. It is more likely to occur with paroxetine. Some centres try to prevent it by gradually discontinuing medication in the third trimester but this carries a high risk of relapse. NB: serotonin toxicity may give very similar symptoms to its withdrawal syndrome.[15]

Where depression is severe and treatment resistant, strategies include a trial of a different single drug or ECT. There is limited available evidence but it appears effective for severe mental depression in pregnancy and that the risks to fetus and mother are low.[16] Lithium augmentation should be avoided.

Lithium

Any woman taking lithium in pregnancy needs an individualised psychiatric care plan, involving maternity services and the woman herself, for lithium management throughout pregnancy and the peripartum. This needs to include:[4]

Frequency of monitoring and dose adjustment.

Potential for interaction with other medications used in pregnancy.

Preparation for and mode of delivery.

Risks to the neonate.

There are potential risks to the infant when a breast-feeding mother takes lithium, so mothers should be discouraged from breast-feeding. If they decide to breast-feed, the infant needs close monitoring including serum lithium levels, thyroid and renal monitoring.

Referral

Refer to perinatal psychiatric services (or general psychiatric services where not available):[9]

Women with recurring depression or bipolar disorder at the outset of their pregnancy.

Women with new onset depression in pregnancy when:

The woman is severely depressed and at risk of self-harm or suicide.

There is evidence of severe self-neglect.

There are psychotic or manic features.

The woman may have undiagnosed bipolar disorder or has a history of other severe mental illness.

There is a family history of severe depression, puerperal psychosis, suicide, or bipolar illness.

Consider referral or seek advice when:

Antidepressant treatment is under consideration.

There is uncertainty regarding diagnosis.

The woman has recurrent depression.

The depression is poorly responsive to treatment.

Other factors, including level of functional impairment and comorbidities, should also be considered.

Complications

Antenatal stress or depression is associated with increased risk of:

Miscarriage - this may be mediated by antenatal exposure to antidepressants.

Prognosis

Early detection of depression during pregnancy and its adequate treatment are critical to avoid its persistence into the postpartum period and sequelae such as impaired mother-infant attachments and the consequences this has for children. Exposure to tricyclic antidepressants or fluoxetine in pregnancy does not appear to affect cognition, language development, or the temperament of preschool and early-school children adversely. However, maternal depression is associated with less cognitive and language achievement by their children.[4] This is not universal but tends to occur when the mother is unable to actively engage with the infant.

Whilst women are at generally low risk of suicide during pregnancy, it is a significant cause of maternal death in the year following birth in the UK.[19] Improving awareness of perinatal mental health problems, in all their diversity, is important.

Prevention

Women with pre-existing affective disorder

All women with affective disorders, of reproductive age and potential, should have family planning discussed as part of their routine care. Where women with a past history of severe or resistant depression are planning to become pregnant, referral to specialist psychiatric services for preconceptual advice is appropriate.

The decision to stop or continue medication should be an informed decision made by the woman, with access to available evidence and risk assessment.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.